Lobby New Client Registration Form

1

Are you filling out the registration form:* This field is required.

At our hospital

In advance

2

If you are filling this out in advance, what is your estimated time of arrival, or when is your appointment scheduled? Additionally, please check in with our client service team when you arrive.

3

Have you been to our facility before* This field is required.

Yes

No

4

First* This field is required.

5

Last* This field is required.

6

E Mail* This field is required.

example@example.com

7

Street Address* This field is required.

8

Apt

9

City* This field is required.

10

State* This field is required.

11

Zip* This field is required.

12

Please check your primary phone number* This field is required.

Cell Phone

Home Phone

Work Phone

13

Cell Phone* This field is required.

14

Home Phone

15

Work Phone

16

Secondary Contact Name

17

Secondary Phone

18

Relation

19

Pet Name* This field is required.

20

Breed* This field is required.

21

Species* This field is required.

Dog

Cat

22

Sex* This field is required.

Female

Male

23

Is your pet neutered / spayed* This field is required.

Yes

No

24

Color

25

Years blanks Months blank

26

Name of Veterinarian

27

If you were referred by a veterinarian other than your Primary, please list name / clinic below

28

Does your pet have insurance* This field is required.

Yes

No

29

If yes, what type of insurance

Trupanion

Fetch

Embrace

30

If other, please specify insurance

31

Policy Number (if known)

32

Would translation services be helpful to you?

Yes

No

33

If "Yes" What language will we need to translate?

34

Do you qualify for one of the discounts listed below

Rescue Organization

First Responder

Military & Veterans

Vet & Vet Support

I do not qualify

35

If you qualify for one of the discounts listed above, please provide one of the following documents to verify: DOCUMENTATION OF 501C3, / FIREFIGHTERS ID / EMTS ID /PARAMEDICS ID / LAW ENFORCEMENT ID / MILITARY ID / DD214 / VA ID / MD VET LICENSE, VETERINARIAN ID OR NAME BADGE / VET TECH ID OR NAME BADGE

36

You will be advised of the recommended diagnostic procedures and associated costs before proceeding with a treatment plan for your pet. Payment is required at the same time your pet is discharged from the hospital. If your pet requires hospitalization, a minimum pre-payment of 100% of the high end estimated charges is required. By signing below, I authorize Dogs & Cats Emergency & Specialty to charge my credit card or other payment method on file for any remaining balance due, if no other form of paymentis provided.

I understand that any balance remaining after discharge of my pet, if not collected within 30 days, may be placed in collections with a third party. I accept responsibility for payment of any fees associated with collections, including the reasonable attorney's fees and

I am the owner of the above described pet, or, am acting as an agent and have authorization from the owner to consent to the pet's treatment. I am at least 18 years of age. PHOTO ID REQUIRED- PLEASE ATTACH BEFORE FORM SUBMISSION I accept full financial responsibility for the services provided.

37

I give DCES permission to administer CPR to the above referenced pet if necessary:* This field is required.

Yes

No

38

Print Name* This field is required.

39

Signature* This field is required.

Clear

40

Date* This field is required.

Date

41

Please upload a copy of your state ID or driver's license for verification purposes. Click "Browse Files" and select upload photo. Place your ID in the card slot attached to the back of this iPad.* This field is required.

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